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What components are in the dermis?
Nerves, sensory receptors, blood vessels, lymphatics
What does the eccrine gland secrete and at what age does it mature?
- - It secretes sweat (saline)
- - Matures at 2 months of age
What do apocrine glands secrete, name six locations, when do they mature, and what happens to them as you age?
- - Secrete fluid in response to heat and emotional stimuli
- - Open in hair follicles
- - axilla, nipples, areolae, anogenital area, eyelids, and external ears
- - They activate during puberty
- - They decrease with aging, so the elderly are prone to over heating
What 2 things do sebaceus glands lubricate?
- Skin and nails- which leads to soft and supple skin
- w/o have dry and wrinkling skin
What 3 things occur with overproduction of sebaceus glands?
- 1. Cradle cap
- 2. Seborrheic dermatitis
- 3. Acne
What are the characteristics of vellus hair? (4)
- 1) Soft
- 2) Non pigmented
- 3) Fine
- 4) Covers most of the body
What are three characteristics of Terminal hair? Name 3 examples
- 1) Coarse
- 2) Pigmented
- 4) Thick
- Eye brows, scalp, axilla
Does the Epidermis contain blood vessels?
What is the subcutaneous tissue made up of and what are two of its functions?
- It is made up of adipose tissue.
- 1) Temperature regulation
- 2) Insulation
Name six functions of skin.
- 1) Thermoregulation (sweat and fat insulation)
- 2) Protection
- 3) Vitamin D production
- 4) Absorption and secretion (metabolic waste)
- 5) Replace cells in surface wounds (from bottom to top)
- 6) Sensory perception (pain, touch, temperature, and pressure)
When does uremic frost occur?
Uremic frost occurs when a patient has renal failure and is not on dialysis. Then the metabolic waste seeps through the skin making a white powder.
What is Xerosis and who is it commonly seen in?
Excessive dryness that is commonly seen in the elderly
What is pruritus? What two groups is it commoly seen in and why?
- - It is itching
- Commonly seen in the elderly due to xerosis
- Also commonly seen in patients with liver or kidney disease because of inability to metabolize and remove waste from their system.
Name 4 skin diruptions that medications can cause.
- 1) Rash
- 2) Pruritis
- 3) Photosensitivity
- 4) Skin eruptions
What is Trichotillomania and what causes it?
It is pulling out of one's hair due to stress/anxiety.
What is hirsutism and what causes it?
It is excessive terminal hair growth that is caused by androgen productions by the adrenal glands.
Which type of infections are skin folds at risk for and name 3 of these places.
- Fungal infections and lesions
- groin, under the breast, and between the toes
Name 15 things to subjectively assess for the skin.
- 1) Previous history of skin disease
- 2) Changes in pigmentation
- 3) Changes in mole size, shape, and color
- 4) Xerosis
- 6) Seborrhea
- 7) Pruritis
- 8) Excessive bruising
- 9) Rash or lesions
- 10) Medication effects
- 11) Alopecia
- 12) Hirsutism
- 13) Nail change
- 14) Skin fold assessment
- 15) Self-care/ sun exposure
What is vitiligo, what is its progression, and who is it more common in?
It is an absence of melanin pigment in patchy areas that is progressive and commonly seen in people with darker skin.
What are ephelides and how are they documented in the chart?
It is another word for freckles and they are not documented because they are so common.
What are pigmented nevi? What disease process is most commonly diagnosed when changes in these occur?
They are moles. Changes could be an indication of malignant melanoma.
What is pallor? What are 4 common causes?
- Pallor is a white coloring to the skin that indication blood profusion problems.
- 1) Anxiety/ fear- activation of SNS causes vasoconstriction
- 2) Shock (shunting blood from periphery to major organs)
- 3) Anemia/ arterial insufficiency (decreased blood supply to PVS)
- 4) Cold/cigarrete smoking (decreased blood supply to PVS)
What is it called when a man who is smoking's hand turns white and what caused it to do so?
- Smoking causes vasoconstriction
Why might a patient's skin turn whitish when he is in shock and what is this called?
Because all of the blood is going to major organs instead of the PVS and it is called pallor
Why does anxiety cause the skin to turn a whitish color and what is it called?
Becaue during fear or anxiety the vessels vasoconstrict, so less blood goes to the PVS. It is called pallor.
How would you describe a patient with erythema?
The patient would appear red and flushed because of the collection of blood in one area.
What is hyperemia? Name three causes.
Hyperemia is excessive blood that causes erythema. It is caused by infection (cellulitis), fever, and increased emotion.
Name 4 causes of erythema.
- 1) Hyperemia
- 2) Carbon monoxide poisoning
- 3) Venous stasis
- 4) Polycythemia
What is polycythemia
What is cyanosis and what causes it?
Cyanosis is a bluish coloring of the skin due to hypoxia
What is central cyanosis? What is the cause?
- Central cyanosis is when parts of the trunk are blue (i.e. tongue, lips, oral mucosa)
- The cause is less than 5 gm of unoxygenated hemoglobin secondary to pulmonary problems.
What is peripheral cyanosis? What causes it?
- Peripheral cyanosis is when the extremities are blue (i.e. fingers)
- It is caused by vasoconstriction.
What is jaundice and what are the causes?
- Jaundice is a yellow coloring to the skin.
- It is caused by rising levels of bilirubin in the blood with reabsorption into the skin. Bilirubin is a byproduct of RBC break down due to Biliary obstruction or ineffective bilirubin breakdown due to liver disease or immature livers (infants)
What are two additional signs of biliary blockage?
- Clay colored feces
- Dark yellow urine
What is nutritional status affected by?
The intake, use, and storage of nutrients. This includes the macronutrients and micronutrients
What are Macronutrients? (3)
- 1) Carbohydrates
- 2) Proteins
- 3) Fats
What are macronutrient used for? What are adequate macronutrients used for?
- Energy and the unused ones are stored as fat
- - Growth
- - Normal body system function
- - Resistance to infection
- - Growth and repair
Patients that are in the hospital tend to be malnurished because of their disease process. What are these patients more prone to?
What are micronutrients?
- - Minerals
- - Electrolytes
What are micronutrients functions? (4)
- - Require for use of major nutrients
- - Provide structure for bones, teeth, cells membranes and connective tissue
- - Regulate cellular metabolism, maintain acid-base balance, and maintain oncotic pressure
- - maintain nerve & muscle irritability for transmission of impulses & contraction of muscles
If a patient were to eat 3,500 calories more in a day, but not increase his activity more how much weight would he gain?
How many additional calories does it take for a person to gain one pound?
How many calories per a gram are in carbohydrates?
How many calories per a gram are in fats?
How many calories per a gram are in proteins?
What does CHO stand for?
What does PRO stand for?
What is a word for being over nourished or under nourished?
What does malnurishment cause an increase in?
Mortality and morbidity
Where are carbohydrates stored in the body and as what?
Stored in the liver and muscle as glycogen
Approximately how much energy is stored in the body as carbohydrates and what happens to these stores after not eating for 15-20 hours?
250 grams or 1,000 calories. This storage is depleted after 15-20 hours of not eating.
How are proteins stored in the body? How much is stored?
- Proteins are stored as plasma proteins, hemoglobin, hormones, antibodies, clotting factors, and skeletal and smooth muscle
- approximately 6,000 gm/ 2,400 cal of protein are stored in the body
What purpose do stored proteins have in the body and what happens if they are broken down?
They play a major role in proper functioning of the body, and so there can be big problems if they are depleted/ broken down, such as hemorrhaging from depletion of clotting factors.
Approximately how much fat is stored in the body, what is its function, and what happens if it breaks down?
- 1500 gm/ 135,000 cal are stored in the body depending on the person's intake
- They provide energy
- No major malfunction occurs with breakdown
What are fats stored as in the body?
What is the order of macromolecule storage breakdown in the starvation process and what is the time line if given?
- First the the glycogen (carbohydrates) are broken down from the muscle and liver in the 1st 15-20 hours
- Second the fat storage is depleted
- Then the body metabolism decreases to try to conserve the body's proteins
- Last of all the proteins are broken down
In what type of patients would you see the starvation process? Give an example.
In patients with chronic illness, such as cancer patients
People who partake in crash dieting are part of what process?
the starvation process
For the starvation process what 4 problems/impairments can occur once protein is broken down?
- 1) impaired wound repair
- 2) decreased resistance to infection
- 3) impaired work of breathing
- 4) multi-system organ failure and death
Explain the stress process.
- Similar to the starvation process the carbohydrate stores (glycogen) is depleted in the first 15-20 hours.
- Next is protein loss
- Contrary to the stravation process: The metabolisms increases because of the release of stress hormones
- this causes increased metabolism of proteins and fat.
What are 2 common symptoms in patients that are going through the stress process?
- Decrease in insulin release
- This is why stressed patient have high BG
Name the four stress hormones involved in the stress process.
- - catecholamines [adrenal medulla]
- - growth hormones [anterior pituitary]
- - glucocorticoids [adrenal cortex]
- - glucagon [alpha cells of pancreas]
What type of state are patient undergoing the stress process under and what is the consequence of being in this state?
They are in a highly catabolic state. This leads to an increased break down of proteins and fat. Some patient can lose 20 lbs a week in this state
What does catabolic mean and what is its opposite?
It means breakdown and it is the opposite of anabolic state, which is a building process
At what age in the brain full size?
8 years old
Before what age should children not be on low fat diets?
2 years old
Fat is essential for which type of development in children?
During growth spurts in adolescents are more or less calories required to maintain weight?
More (common sense)
How many calories less do post puberty adolescents need to prevent weight gain and obesity?
How much weight do women on average gain each year between the ages of 20-40 years?
1 lb a year
List 8 reasons that the elderly may be malnourished.
- 1) Loss of teeth
- 2) Decreased income
- 3) Decreased senses
- 4) Decreased GI motility
- 5) Loss of spouse
- 6) Social isolation
- 7) Medications side effect that affect GI function
- 8) Chronic disease
How do nausea and diarrhea affect caloric intake?
- Nausea decreased amount of food taken in
- Diarrhea affects the amount of food absorbed.
Why do the elderly require less calories?
Less activity and slower metabolism
Which patients should have nutritional assessments done on them?
- Those who have lost 10 or more lbs unintentionally
- The overweight (IBW of greater than 120%)
- The underweight (IBW of less than 80%)
- and those who have a history of illness that causes malabsorption and impaired nutrient intake
How is the patient's dietary information collected in the hospital and why can this way be difficult?
- It is collected by direct observation.
- This can be difficult because visitors may eat some food and patients may save food for later
What demographic is not accounted for in the food pyramid's recommended serving sizes?
A person's height is not accounted for
What is the name of the report that NCEP (National Cholesterol Education Program) gives every year and what nutrient is the recommendation for?
The report is ATP (adult treatment panel) give recommendations on fat intake
What are NCEP Requirements?
- Total fat: 25-35% of total calories- same for children and adults
- Saturated fat: < 7% of total calories-Solid at room temperature (e.g., meat fat, palm oil, coconut oil)
- Polyunsaturated fat: < 10% of total calories- e.g., corn oil, safflower oil
- Monounsaturated fat: < 20% of total calories- e.g. olive oil, avocado
- Cholesterol: <200 mg/day- a type of saturated fat that comes from an animal source.
Do saturated fats come from animal sources?
Sometimes but not always
If a food is cholesterol free does that mean it is free of unsaturated fats?
Why should you be weary of trans fats?
because they are highly athrogenic
Approximately what percent of calories in fast food is from fats?
Carbohydrates (CHO) should be what percent of your daily calories?
Protein should be what percent of your daily calories?
How many grams of fiber should a person ingest in a day?
25-30 gm/ day
What is considered one drink of alchol?
- 1- 5 oz glass of wine
- 1- 12 oz bottle/ can of beer
- 1 oz hard liquor
What is binge drinking?
greater than or equal to 5 drinks on one occasion
How is the grams of fat able to be consumed in a 2,000 calorie diet calculated.
- 1) Take 2,000 multiply by 0.35 for (35%) = 700
- 2) Take 700 and divide by 9 (calories per gram in fat) = 77
- 3) patient can consume 77 grams of fat a day
What types of milk should adults be drinking to meet the NCEP guildlines for percent fat in a day?
1% or Skin, no less calcium in skim
What does the ACE study say?
Adults that had traumatic events in childhood are at a greater risk of addictive behavior that can cause health problems, such as smoking and over eating
If medications are not taken as directed (with or without food) how could it effect a person's nutrition?
It could effect the absorption and metabolism of nutrients
How do the prices of fruits and vegetables compare to fatty foods? What effect does this have on those with less money?
Healthier food costs more, so this causes people with less money to eat foods that are higher in fat.
For general appearance what does WDWN stand for?
Well Developed, Well Nourished
What does an edematous appearance indicate?
A patient with decreased intravascular protein, fluid moves out of blood vessels into interstitial spaces (d/t decreased oncotic pressure)
How is ideal weight calculated?
- In women: 100 lbs for 5 ft plus an extra 5 lbs for each inch more
- In men: 106 lbs for 5ft plus an extra 6 lbs for each inch more
Ideal body weight may vary by what percent depending on body frame?
What are the BMI categories?
- < 18.5% Underweight
- 18.6-24.9% Normal
- 25-29.9% Overweight
- > 29.9 Obese
Name 4 diseases that increase as the BMI increases.
- 1) HTN
- 2) DM
- 3) Cardiovascular diseas
- 4) Osteoarthritis
What steps do you take to determine if a person is at nutritional risk?
- 1) Take the patients body weight divided by IBW: Mild malnutrition 80-90% of IBW
- Moderate malnutrition 70-79% of IBW
- Severe malnutrition < 70% of IBW
- 2) ((Usual weight- current weight) / usual weight) * 100
- > 5% in 1 month
- >7.5% in 3 month
- >10% in 6 month
Are apple or pear shaped individuals at greater risk of cardiovascular disease?
What is the waist size for men and women associated with a greater risk of cardiovascular disease?
- Women: greater than 35 inches
- Men: greater than 40 inches
4 things obesity predisposes a person to.
- 1) DM
- 2) Cardiovascular disease
- 3) HTN
- 4) Metabolic syndrome
What type of measurement is the tricepts skin fold test and what are the results?
- It is an anthropometric measurement. <10% fat= undernutrition
- >10% = over nutrition
What is basal metabolic rate, how is it expressed, and what regulates it?
- the minimal rate of energy expenditure needed to sustain life at rest
- expressed as calories
- regulated by thyroxin (thyroid hormone)
What causes an increased BMR? (6)
- Children and pregnant women
- Lean body
- Hot or cold environmental temps
- Increased thyroxin
What causes a decrease in BMR? (4)
- Fasting or starvation (hormone effects)
- Decreased thyroxin levels
How do you calculate the caloric need of children up to the age of 12?
1,000 calories for the first year plus another 100 calories per a year.
What are 3 reasons for height decreases in men and women?
- Vertebral space
- Bent knees
How muct on average does height decrease for men and women?
- Women: 2 inches
- Men: 1.25 inches
What are two names for abnormal levels of lipids in the blood?
What is nitrogen a product of?
What do higher levels of BUN indication?
- Protein catabolism
What are the normal hemoglobin levels?
- Women: 12-16 g/dL
- Men: 14-18 g/dL
How do you determine the hematocrit value?
It is three times the hemoglobin
What are 2 causes of increased hemoglobin levels?
- 1) Polycythemia
- 2) Dehydration
List the process of increased hemoglobin due to polycythemia.
Chronic hypoxia causes increased erythropoietin from the kidneys which stimulates the bone marrow to produce more RBCs which causes polycythemia.
Process of increased hemoglobin due to dehydration.
Results in hemoconcentration of blood.
What are the normal hematocrit values?
- Females 36-46%
- Males 37-49%
What are the normal levels of cholesterol, HDL, LDL, and triglycerides?
- Cholesterol- < 200 mg/dL
- HDL- > 50 mg/dL
- LDL- < 160 mg/dl (0-1 CAD risk factors) *
- < 130 mg/dl (≥ 2 CAD risk factors)
- < 100 (CAD, DM)
- < 70 in some cases
- Triglycerides- <150 mg/dL (fast for 12 hours)
What are 7 risk factors for CAD?
- - Gender
- - Female > 45
- - Male > 55
- - Smoker
- - HTN or HTN treatment
- - HDL < 40
- - FHX of premature CAD
- - father/brother <55
- - mother/sister < 65
4 factors that influence lipid levels?
- - Hight saturated fat diet
- - Low saturated fat diet &/or malnutrition
- - Exercise
- - Genetics
What does serum albumin measure, what is its half life, and what is the normal levels?
- It measures the visceral protein stores.
- 17-20 days.
- Indicates thes state of nutrition from three weeks previous.
- 3.5 to 5.5 gm/dL
What does serum ferrin measure andwhat is the half life?
- It measures protein that carries iron.
- Half life is 8-10 days
- Earlier indicator of malnutrition
Describe two defining characterics of prealbumin regarding its half life and display of malnutrition.
- Half life of 2-3 days
- More reflective on current nutrional state.
What is normal nitrogen balance level and what does a high nitrogen level indicate?
- Normal level: 8-25 mg/dL
- Muscle trauma/destruction, decreased excretion as seen in Renal failure, or high protein intake
What cause primary malnutrition? Name two diseases and what the individual with them is lacking.
- Primary (dietary deficit)
- Marasum- Protein and calorie malnutrition (cancer)
- Kwashiorkor- Protein deficit and high in carbohydrates
What are two causes of secondary malnutrition?
- Medication side effects